Okinawan Goju-Ryu Karate-Do GoshinKai, LLCHeadquartersPO Box 23

Oak Ridge, New Jersey 07438GOSHINKAI MEMBERSHIP FORM

Application is hereby being made for membership in theOkinawan Goju-Ryu Karate-Do GoshinKai. Please checkthe type of membership that you are requesting in the boxbelow:

New Membership $50Renewal Membership $35Dojo Membership $75

Inactive Membership $15

Supporting Membership $10

Includes membership fee for Dojo Kancho

GoshinKai membership number(required info. for renewal applicants)

Date

Name

Address

City Zip Code

email

Phone Number

Date of Birth

State

Age Fax Number

Cell Phone Number

Dojo (club) Name

Instructor's Name

Address

Date of last promotion Present Rank

Style of Okinawan Karate

Terms & Conditions:Check this box if you are a Parent or Guardian of a Minor Child and hereby give consent for your child to registerfor membership in the Okinawan Goju-Ryu Karate-Do GoshinKai, LLC. By checking this box, you indicate that youhave read, understand and agree to all terms and conditions set forth below.

Check this box to indicate that you have read, understand and agree to all terms and conditions set forth below.

I do hereby voluntarily submit my application for membership in the Okinawan Goju-Ryu Karate-Do GoshinKai, LLC.,hereafter also referred to as “Association.”

***Remember to read the Terms and Conditions above and check the box upon acceptance.

I hereby certify that the information enclosed herein is true and correct.I agree to obey all rules and regulations as prescribed by the Okinawan Goju-Ryu Karate-DoGoshinKai, LLC., and pledge to uphold the traditions, conduct and code of ethics of the martial arts. The “Association”reserves the right to revoke or terminate membership if the above named person fails to obey any of such rules andregulations as prescribed by the “Association,” and fails to uphold the traditions, conduct and code of ethics of themartial arts. I understand that upon termination of membership, I forfeit all money in payment of membership or rankcertification fees. In addition, I agree that upon termination of membership I may no longer wear the patch belonging tothe “Association,” and will no longer represent any affiliation or membership of the “Association."I further agree that any martial arts instruction that I receive will be used responsibly andwill not be used except in an unprovoked attack, and that any such misuse may result in my immediate dismissal fromthe “Association.” The Okinawan Goju-Ryu Karate-Do GoshinKai, LLC. recommends an examination by a physician priorto participation in any martial arts instruction and/or progressive physical exercise. Such examination is particularlyrecommended and encouraged for individuals who have not been physically active, have a history of heart problems,high blood pressure, chronic illness, recent surgery, diabetes, high cholesterol, lung problems or who smoke, arepregnant or are overweight. Regardless of whether an examination by a physician has been completed, I agree toassume full responsibility for my health and well-being and the risks that accompany any form of physical exercise.I acknowledge and fully understand that martial arts is a potentially dangerous activity and that serious injuries arepossible, including permanent disability and death. I accept the responsibility to refrain from participation in anyexercise, drill or activity that I believe will be harmful and understand that I must evaluate each situation in the contextof my skill and current physical condition.I do hereby assume full responsibility for any and all damages or injuries that I maysustain or incur in any way while attending or participating in any event by the Okinawan Goju-Ryu Karate-DoGoshinKai, LLC. or any affiliated clubs. I hereby release and waive all claims against the Okinawan Goju-Ryu Karate-DoGoshinKai, LLC, its agents, representatives, directors, officers, employees, volunteers, affiliated clubs, sponsors, dulyinvited guests or any other parties involved in said “Association” from and holds them harmless against and waives anyclaims, damages, causes of action and/or liability, costs or expenses including, but not limited to, all attorneys’ fees anddisbursements up through and including any appeal, with respect to my attendance or participation in any event as amember of the Okinawan Goju-Ryu Karate-Do GoshinKai, LLC.

I agree to allow without compensation, the unrestricted use of any photographs,films or videotapes of myself.

INDEMNIFICATION BY PARENTS OR GUARDIANSI, the Parent or Guardian of a minor child, agree not to bring any claim or suit against and shall indemnify and holdharmless the Okinawan Goju-Ryu Karate-Do GoshinKai, LLC. its agents, representatives, directors, officers, employees,volunteers, affiliated clubs, sponsors, duly invited guests or any other parties on behalf of my child for any injury orharm sustained, and for any and all judgments, costs, attorney fees and other expenses incurred as a result of abreach of this agreement.

SEVERABILITYI agree that if any clause, sentence, phrase or statement is found unenforceable orinvalid by and Court of law, the remainder of the document shall remain valid enforceable and the invalid clause,sentence, phrase or statement shall be considered struck from the document.

Should you have any questions regarding membership in the Okinawa Goju-Ryu Karate-Do GoshinKai, LLC. , pleaseemail our Membership Director at: membership@goshinkaiusa.org

Make check payable to: ‘GoshinKai” and mail payment with membership application form to:

Okinawan Goju-Ryu Karate-Do GoshinKai, LLC. P.O. Box 23 Oak Ridge, New Jersey 07438